Top health insurance trends based on quality measures

Quality measures that changed significantly

Between 2023 and 2024, the health insurance industry saw some telling changes in quality measure performance.

"We were really excited when it comes to diabetes care. That has really had some strong improvements," Connor shared.

Payers place a lot of focus on diabetes care, Connor indicated, and for good reason. Over 11% of the U.S. population had diabetes in 2021 and one in three Americans had prediabetes, according to the National Institute of Diabetes and Digestive and Kidney Diseases. As a result, the nation spent around $412.9 billion on the disease in 2022.

In 2024, payers improved their performance on diabetes-related quality measures. Across all product lines, there were improvements in HBA1c control, blood pressure control and kidney health evaluations.

"That is a great win and means that insurers are incentivizing proper care for their patients who are trying to manage diabetes," underscored Connor.

Transitions of care, especially for older adults, also saw quality improvements, particularly in Medicare. Beneficiaries can easily fall through the cracks when they are being moved from one facility to another, one floor to another, or even one doctor to a different shift doctor, according to an article by the Agency for Healthcare Research and Quality. Miscommunication, medication errors and failure to prepare caregivers can lead to poor health outcomes and poor patient experience.

Higher scores on transitions of care might mean that payers are incentivizing better practices among providers. Streamlining communication and consistently following up on patients who have transitioned from one environment to another can prevent adverse events and improve healthcare quality. Medication reconciliation is another key factor that ensures a smooth changeover, reducing unwanted drug interactions. This metric also saw an improvement in the 2024 NCQA Health Plan Ratings.

Some quality measure performance fluctuations are harder to explain than others. For example, pharyngitis testing received a boost in the 2024 ratings across all product lines. Pharyngitis is simply a sore throat.

"That one is a little bit more puzzling," acknowledged Connor. "But there was definitely a downtick on that during the [COVID-19] pandemic, so this may just be recovery back to normal."

Unfortunately, shifts in performance on quality measures were not all positive. Childhood immunizations dropped in the commercial and Medicaid product lines. The metric is particularly important for maintaining herd immunity. Due to its impact not only on children but on the next generation as nonimmunized children become adults, this is one quality measure to pay attention to in the future.

Growth areas: health equity, patient experience

Looking to the future, Hundle highlighted two growth areas on which the payer industry can focus some of its quality improvement efforts: health equity and patient experience.

"NCQA believes there's no equity, no quality without equity," Hundle stated.

The organization introduced health equity measures into its health plan ratings system two years ago. The threshold was set very low in the first year but increased last year so that the 2024 NCQA Health Plan Ratings were a little more competitive on the health equity requirement. As a result, Medicaid plans emerged as leaders in the health equity space because that is the segment with the most equity data sources due to existing incentives.

NCQA plans to continue creating health equity initiatives and payers should anticipate a greater push for health equity data in the future, Connor indicated.

One initiative that will come into play in 2025 is the Language Diversity of Membership HEDIS measure. This metric assesses whether a health plan identifies members' preferred written and spoken languages.

In addition to health equity, payers can focus on growth in the patient experience arena.

"Listen to your members," Hundle urged health plans. "What are they saying? What are their experiences like? Are they able to get the care they need in a timely, efficient manner? Can they get their claims paid on time without too many hoops to jump through?"

Health plans with high member satisfaction tended to exhibit three qualities, according to J.D. Power's "2024 U.S. Commercial Member Health Plan Study." They scored well on financial and time costs, offered convenient access to care and gained members' trust.

Role of quality measures in member empowerment

Quality measures can indicate, for example, that payers should dedicate more resources and effort to improving patient experience.

"Sometimes [health plans] pride themselves on being particularly good in an area, and this is a good way to see whether or not there's been maintaining that quality that they were hoping," Connor said.

But healthcare quality measures are also a tool for members.

Through reports like NCQA's, health plan members can get an objective perspective on their payers' performance and can switch plans based on performance in certain areas. Their enrollment then acts as a vote in favor of a health plan that might have a better approach to the aspects of care that are most important to members.

"Members can help drive improvements in the payer space by saying, 'You know, I'm not getting the care I need for XYZ, I'm going to go with this other plan,' if they're fortunate enough to have that option," Hundle explained.

Using these trends along with their own data as guideposts, health plans can prioritize and focus their efforts for future health plan quality reports on healthcare quality measures.

Kelsey Waddill is a managing editor of Healthcare Payers and multimedia manager at Xtelligent Healthcare. She has covered health insurance news since 2019.